SSA Award Application

Office Use Only

___________ ____________ ______ ____________ __________ ____________ _______________

Hold Date Approval Date By Letter Date Soaring Pub Denial Date SC3 Reason

SSA Form B-1 8 20/ 5/1

Submit by mail to:

SSA, PO Box 2100 Hobbs, NM 88241

Attn: Badge Claims

For any flight documented by approved data recorder, attach please both pages of a completed SSA Badge & Record Workshee .t

I. PILOT INFORMATION: non-members please enclose $20 fee for processing FAI badge claims

(a) Pilot: _______________________________ Date of Birth: _______________ SSA Member #: _____________

(b) Address: ____________________________ City: ________________________ State: _____ Zip: ___________

(c) E-mail: ___________________________________

II. PILOT CERTIFICATION: I hereby certify this flight was conducted in accordance with the FAI Sporting Code, in

compliance with all the glider manufacturer's and national operating limitations, and in accordance with national flight regulations respecting airspace use, night flight, etc. I apply for the award(s) low. bechecked

Pilot Signature: __________________________________________ Date: _______________________________

Altitude Claim(s): Silver Gold Diamond Symons Wave ($40 fee applies)

Duration Claim: Silver/Gold

Distance Claim(s): Silver Gold Diamond Goal Diamond Distance

Diplome Claim: 750 km 1000 km 1250 km Other Diplome: __________km

Other Awards Barringer Trophy Century Award (Pilot age 20 or younger)

*See program rules *State Record(s) *SSA Distance Award ($10 fee applies)

III. FLIGHT DATA SUMMARY

(a) Flight Date: _________________ Is the aircraft a motor glider? YES NO

(b) Aircraft Make & Model: __________________________ N#: ______________

(c) Take Off Site: ___________________________________ State: ____________ Elevation: ____________ MSL

(d) Time of release (or last motor glider Means of Propulsion use), Local time: ____________________________

(e) Landing Site: ____________________________________ State: ____________ Elevation: ___________ MSL

(f) Landing time (end of the ground roll), Local time: _____________________

IV. OBSERVER CERTIFICATION: Check ONE and complete:

GPS data supports this application; I provided supervision of this flight as required by ortingSp odeC Section 3, and have attached the SSA Badge & Record Worksheet I completed.

This application is for Silver Duration only and I provided the continual attention required to confirm 5 hours were flown.

OBSERVER’S NAME (please print)____________________________________ SSA MEMBER #: _____________________

SIGNATURE: __________________________________________ E-MAIL: _______________________________________